Provider Demographics
NPI:1740335165
Name:NORTHWEST SUBURBAN SURGICAL SERVICES
Entity type:Organization
Organization Name:NORTHWEST SUBURBAN SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LEIB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-477-8911
Mailing Address - Street 1:39 S VIRGINIA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5826
Mailing Address - Country:US
Mailing Address - Phone:815-477-8911
Mailing Address - Fax:815-477-8911
Practice Address - Street 1:39 S VIRGINIA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-5826
Practice Address - Country:US
Practice Address - Phone:815-477-8911
Practice Address - Fax:815-477-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical